Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: TARLACPROVINCIALHOSPITAL@yahoo.com

Document Name :

TPH POLICY ON CONTINIOUS

QUALITY IMPROVEMENT

Date Created :

25 September 2016

Approved By :
SHELLEY ANN M. MANGAHAS, MD,
MHA, FPAO
OIC Chief of Hospital

Reviewed By :
HEDDAH A. URBIS, MD, FPCP
Chairperson, Quality Assurance Committee
Issued By :

TPH Quality Assurance Committee

Responsibility of Updating :

TPH Quality Assurance Committee

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: TARLACPROVINCIALHOSPITAL@yahoo.com

TABLE OF CONTENTS
NO.

PARTICULARS

INTRODUCTION

DEFINITION

METHODS OF QUALITY ASSURANCE

3.1

Concurrent or On-The-Spot-Review

3.2

Retrospective Review

EXTERNAL OR INTERNAL QUALITY ASSURANCE

PROCESS OF QUALITY ASSURANCE

NEED FOR QUALITY IMPROVEMENT

RECORDS IN QUALITY IMPROVEMENT

STEPS FOR QUALITY IMPROVEMENT

APPROACHES FOR QUALITY ASSURANCE

9.1

General Approaches

9.2

Specific Approaches

10

CRITERIA FOR EVALUATION OF QUALITY OF SERVICE IN PATIENT

CARE

11

EVALUATION OF QUALITY OF PATIENT CARE

11.1

Expectation of Patients / Relatives

11.2

Expectation of the Physician

12

QUALITY HEALTH OUTCOME MODEL

13

ROLE OF NURSES IN QUALITY ASSURANCE

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: TARLACPROVINCIALHOSPITAL@yahoo.com

1. INTRODUCTION
Quality assurance is achievable through an ongoing evaluation of patient care which
would assure the hospital that all that was done for the patient was done to justify
diagnosis, treatment and outcome and to pinpoint inadequacies in medical care for
rectification for the future cases.
2. DEFINITION
Quality assurance is defined as all actions taken to establish protect, promote and
improve the quality of health care
3. METHODS OF QUALITY ASSURANCE
Quality assurance in patient care having various methods. They are as follows;
3.1

CONCURRENT OR ON-THE-SPOT-REVIEW
A hospital administrator uses this methods routinely so far as nonclinical aspects
of hospital care are concerned, in the form of daily and periodical administrative
rounds.
(1) As the rounds progresses, the visiting physician should look into the patients
case records, enquire from each patient about his/ her progress, treatment and
diet, peruse nurses report, book and treatment book, and even inspect the
house keeping activities and sanitation of the ward and other aspects
connected with patient care.
(2) The analysis of records immediately after discharge in the ward itself can
prove fruitful in obtaining the final diagnosis from the physician before the
record arrives in the medical record department.
(3) This can assist in providing accuracy of information in the medical record
itself, the most frequently used data source in the hospital.

3.2

RETROSPECTIVE REVIEW
3.2.1

Pre requisites of retrospective audit

There are 3 fundamental pre requisites that need to be fulfilled before the
programme is instituted.
(1)
(2)
(3)

Good medical records.

Establishment of criteria for diagnosis, investigations and treatment
Co-operation and involvement of medical staff.

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: TARLACPROVINCIALHOSPITAL@yahoo.com

The medical record has to be sequentially filled and a face sheet affixed
to each case record before it is presented to the evaluation committee.
4. EXTERNAL OR INTERNAL QUALITY ASSURANCE
External quality assurance is seen as being concerned with the setting by independent
outside authorities of explicit standards of service over wide areas of health care system.
Internal quality assurance is seen as essentially a local exercise, whereby the activities of
physicians and surgeons are subjected to a confidential review by their peers designed to
improve patient care and encourage professional self-evaluation.
5. PROCESS OF QUALITY ASSURANCE
Help patients and potential patients by improving quality of care.
Assess competence of medical staff, serve as an impetus to keep up to date and
prevent future mistakes.
(3) Bring to notice of hospital administration the deficiencies and in correcting the
causative factors.
(1)
(2)

The process can also help to exercise a regulatory function, restricting procedures. This
cannot but help the medical staff to improve upon their clinical and professional
judgment. By timely verification, it cannot but help provide assurance for future actions
so that better methods could be used.
6. NEED FOR QUALITY IMPROVEMENT
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)

Establish responsibility and accountability for a quality programme.

Define the scope of service for a clinical area.
Improvement of existing obsolete processes and procedures.
Improved layout of office and working environment.
Economy in human effort.
Improved performance.
Job satisfaction.
Improved flow of work.
Standardization of process and products.

7. RECORDS IN QUALITY IMPROVEMENT

Records are an integral part of the communication structure of the health care
organization. Records provide complete information about the client, indicate the extend
and quality of service being rendered, resolve legal issues in malpractice suits and
provide information from education and research. Accurate and complete records are
required by law and must be kept update by all governmental and non-governmental
agencies.

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: TARLACPROVINCIALHOSPITAL@yahoo.com

8. STEPS FOR QUALITY IMPROVEMENT

(1)

Define the key aspects of service for the clinical area.

(2)

Develop quality indicators to monitor the outcomes and appropriateness of care

delivered.

(3)

Establish thresholds for evaluation of indicators.

(4)

Collect and analyses data from monitoring activities.

(5)

Evaluate results of monitoring activities to determine the need for change in practice.

(6)

Resolve problems through development of action plans.

(7)

Reevaluate to determine if the plan was successful.

(8)

Communicate results to the organization.

9. APPROACHES FOR QUALITY ASSURANCE

There are mainly two categories.
9.1

GENERAL APPROACHES
9.1.1

CREDENTIALING
The formal recognition of a person as a professional with technical
competence or of an agency that has met minimum standards of
performance.
Credentialing includes licensure for individuals accreditation for
institution and certification with the features of both licensure and
accreditation.

9.2

SPECIFIC APPROACHES
Specific approaches are implemented voluntary agencies and provider groups
interested in the quality of interactions in their settings. They include,
9.2.1

STAFF REVIEW COMMITTEE (AUDIT PROCESS)

This is a method of evaluation quality of care through appraisal of patient
care process.

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: TARLACPROVINCIALHOSPITAL@yahoo.com

9.2.2

UTILIZATION REVIEW
The process of utilization review is to assure that if care actually is needed
and that the cost is appropriate.

9.2.3

CLIENT SATISFACTION SURVEY

It is yet another method for measuring quality of care. Client satisfaction
is being assessed using in person or telephone interview and mailed
questionnaires. This survey measures the intervention of client care,
attitudes about the care received and the providers of care.

9.2.4

RISK MANAGEMENT
The goal of risk management is to reduce the liability on the part of the
agency and the no: of grievances brought against the agency.

9.2.5

MALPRACTICE LITIGATION
It is typically results from client dis satisfaction with the provider and with
the content of care provider.

10

11

CRITERIA FOR EVALUATION OF QUALITY OF SERVICE IN PATIENT CARE

(1)

Patients satisfaction levels as assessed from the satisfaction survey program and the
complaints received from the patients / relatives.

(2)

Complaints received from the doctors about incompetence negligence / or bad behavior
on the part of personnel handling patients.

(3)

Instances of sampling errors by physician / nurse leading to erroneous reports / results.

(4)

Instance of nosocomial infections attributable to unsafe medical/nursing practice.

(5)

Instance of unexpected complications / death due to negligent performance by the

physician / nurse.

EVALUATION OF QUALITY OF PATIENT CARE

The way to judge the quality of nursing services is from the quality of outcome of patient
care, which means,
(1)

SATISFACTION OF PATIENT / RELATIVES. (EXTERNAL CLIENT)

(2)

SATISFACTION OF PHYSICIANS (INTERNAL CLIENTS)

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: TARLACPROVINCIALHOSPITAL@yahoo.com

11.1EXPECTATION OF PATIENTS / RELATIVES

(1)

To have someone to take care of them continuously during the period of

sickness, sympathetically, willingly and smilingly.

(2)

Someone to attend their basic needs with patience, understanding and

efficiency.

(3)

Someone to provide all the right patient care and medication at the right time
in the right manner as prescribed by the doctors, relieve the pain and suffering
and quickly restore them back to health without any complications or ill
effects.

11.2EXPECTATIONS OF THE PHYSICIANS

(1)

The nurses monitor the patients condition with efficiency and alertness and
inform them immediately any change requiring the physicians intervention.

(2)

Nurses carryout the physicians instructions strictly regarding the

investigations, medications, nutrition, and specialized nursing / other
procedures as per prescribed schedule.

(3)

Nurses take care of the basic needs of the patients provide a safe and
comfortable environment conducive to early healing and nurse them back to
normal health.

(4)

There are no complications / harm to the patients due to any mistakes on the
part of nurses in the performance of above functions.

12 QUALITY HEALTH OUTCOME MODEL

STRUCTURE
PROCESS
OUTCOME
Facility resource personal Standards, attitudes, patient Clients health care goals
mix and skills, philosophy, care plan effectiveness, client met
effectiveness
of
policies and client mix.
satisfaction.
services.
13 ROLE OF NURSES IN QUALITY ASSURANCE.
(1) As an assistant to the treating physician
By assisting the physicians in various procedure as well as carrying out their
instructions for medical management of patients.
(2) In provision of nursing care
A very skilled role requiring continuous responsibility of nursing care of the patients
under their charge.

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: TARLACPROVINCIALHOSPITAL@yahoo.com

(3) Hospitality role

Taking care of all the routine needs (food, clothing, cleanliness, hygiene, sanitation,
accommodation) and psychological support to reassure the patient and relatives anxiety.
Nurses are responsible for managing the caseload of client with needs of varying degrees of
urgency. Using the resources available, the must priority services that will promote the
highest possible level of person and group functioning and health.
Some quality improvement activities for nurses include daily prioritizing care needs,
seeking supervision or skills development for a difficult case, systematizing charting so that
needed documentation is effectively completed, proposing better ways to organize care of
chronically ill client or establishing new agency procedures. All these actions demonstrate
that nurses are evaluating their work and looking for ways to improve care. Staff meetings,
quality circle meetings, peer review and case conferences are common settings for nurses
to brings the lessons of their practice to the large group for examination and potential
adoption.